Accidental falls are among the most common reported adverse events which occur during hospitalization. About 30% result in injury and of these, about a third cause serious injury. Beginning October 1, 2008, the Centers for Medicare &Medicaid Services (CMS) no longer reimbursed hospitals for treatment of injuries resulting from falls which occur during hospitalization.1-4 Although the intent of this rule change is to simultaneously reduce cost and improve the quality of health care in hospitalized patients, it is unknown what the effect of this reimbursement change will have on falls and fall prevention strategies in hospitals. The primary aim of this study is to determine whether this "legislative intervention" is associated with changes in: 1. Total and injurious patient falls. The secondary aim of this study is to determine whether CMS nonpayment for nosocomial injury results in changes in: 2. Use of physical restraints. There is considerable controversy surrounding the use of physical restraints in hospital settings.7,11,12 The adverse effects of physical restraints have been well described;however, it is not clear whether use of physical restraints prevents falls in acute care settings. The tertiary aims of this study are to determine: 3. The relationship between physical restraint use and the risk of patient falls at the level of the: 3a. nursing unit, and 3b. patient, and 4. Whether the relationship between physical restraint use and falls is altered by CMS payment changes at the level of the nursing unit. These aims will be accomplished using two approaches: 1) unit level aims will be addressed using a 54 month quasi-experimental study and physical restraint use 27 months before through 27 months after the CMS payment changes, and 2) patient-level hypotheses will be tested using a matched case-control approach. Two data sources will be utilized. Unit-level aims will be addressed using data from the National Database of Nursing Quality Indicators (NDNQI). Relevant to this application, data on falls, injurious falls, physical restraint use, as well as staffing information have been collected at the level of nursing unit in a systematic manner from nearly 1000 acute-care hospitals from every region of the country. Patient-level aims will be accomplished using data from 24 adult medical and/or surgical nursing units at the four adult hospitals in the Methodist Healthcare System (MHC). These hospitals share a unified electronic medical record system which will allow us to apply many of the approaches to data collection we developed for an NIH-funded trial of proximity alarm monitoring to prevent falls conducted at MHUH. In addition to informing future legislation on patient safety, information from this study will contribute to the long-term goals supporting the development of effective organizational and patient-specific strategies to reduce falls in hospitals. PUBLIC HEALTH RELEVANCE: The primary aim of this study is to determine whether elimination of Medicare payment for injuries sustained in hospitals is associated with changes in the frequency of falls and changes in fall prevention strategies, particularly the use of physical restraints.